What is EMDR Therapy?
Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR therapy includes a set of standardized protocols that incorporates elements from many different treatment approaches. To date, EMDR has helped millions of people of all ages relieve many types of psychological stress.
In 1987, psychologist Dr. Francine Shapiro made the chance observation that eye movements can reduce the intensity of disturbing thoughts, under certain conditions.
Dr. Shapiro studied this effect scientifically and, in 1989, she reported success using EMDR to treat victims of trauma in the Journal of Traumatic Stress.
Since then, EMDR therapy has developed and evolved through the contributions of therapists and researchers all over the world. Today, EMDR therapy includes a set of standardized protocols that incorporates elements from many different treatment approaches.
No one knows how any form of psychotherapy works neurobiologically or in the brain. However, we do know that when a person is very upset, their brain cannot process information as it does ordinarily. An experience becomes “frozen in time”, and remembering the event may feel as bad as going through it the first time because the images, sounds, smells and feelings haven’t changed. Such memories have a lasting negative effect that interferes with the way a person sees the world and the way they relate to other people.
EMDR therapy seems to have a direct effect on the way that the brain processes information. Normal information processing is resumed, so following a successful EMDR session a person no longer relives the images, sounds, and feelings when the event is brought to mind. You still remember what happened, but it is less upsetting. Many types of therapy have similar goals. However, EMDR therapy appears to be similar to what occurs naturally during dreaming or REM (rapid eye movement) sleep. Therefore, EMDR can be thought of as a physiologically based therapy that helps a person see disturbing material in a new and less distressing way.
Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR therapy includes a set of standardized protocols that incorporates elements from many different treatment approaches. To date, EMDR has helped millions of people of all ages relieve many types of psychological stress. Below is a brief description of EMDR therapy.
8 Phases of Treatment
The amount of time the complete treatment will take depends upon the history of the client. Complete treatment of the targets involves a three pronged protocol (1-past memories, 2-present disturbance, 3-future actions), and are needed to alleviate the symptoms and address the complete clinical picture. The goal of EMDR therapy is to process completely the experiences that are causing problems, and to include new ones that are needed for full health. “Processing” does not mean talking about it. “Processing” means setting up a learning state that will allow experiences that are causing problems to be “digested” and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future. The inappropriate emotions, beliefs, and body sensations will be discarded. Negative emotions, feelings and behaviors are generally caused by unresolved earlier experiences that are pushing you in the wrong directions or causing unwanted responses or reactions. The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.
Phase 1: History and Treatment Planning
Generally takes at least 1-2 sessions at the beginning of therapy, and can continue throughout the therapy, especially if new problems are revealed. In the first phase of EMDR treatment, the therapist takes a thorough history of the client and develops a treatment plan. This phase will include a discussion of the specific problem that has brought him into therapy, his behaviors stemming from that problem, and his symptoms. With this information, the therapist will develop a treatment plan that defines the specific targets on which to use EMDR. These targets include the event(s) from the past that created the problem, the present situations that cause distress, and the key skills or behaviors the client needs to learn for his future well-being. One of the unusual features of EMDR therapy is that the person seeking treatment does not have to discuss any of his disturbing memories in detail. So while some individuals are comfortable, and even prefer, giving specifics, other people may present more of a general picture or outline. When the therapist asks, for example, “What event do you remember that made you feel worthless and useless?” the person may say, “It was something my brother did to me.” That is all the information the therapist needs to identify and target the event with EMDR therapy.
Phase 2: Preparation
For most clients this will take only 1-4 sessions. For others, with a very traumatized background, or with certain diagnoses, a longer time may be necessary. Basically, your clinician will teach you some specific techniques so you can rapidly deal with any emotional disturbance that may arise. If you can do that, you are generally able to proceed to the next phase. One of the primary goals of the preparation phase is to establish a relationship of trust between the client and the therapist. While the person does not have to go into great detail about his disturbing memories, if the EMDR client does not trust his clinician, he may not accurately report what he feels and what changes he is (or isn’t) experiencing during the eye movements. If he just wants to please the clinician and says he feels better when he doesn’t, no therapy in the world will resolve his trauma. In any form of therapy it is best to look at the clinician as a facilitator, or guide, who needs to hear of any hurt, need, or disappointments in order to help achieve the common goal. EMDR Therapy is a great deal more than just eye movements, and the clinician needs to know when to employ any of the needed procedures to keep the processing going. During the Preparation Phase, the clinician will explain the theory of EMDR therapy, how it is done, and what the person can expect during and after treatment. Finally, the clinician will teach the client a variety of relaxation techniques for calming himself in the face of any emotional disturbance that may arise during or after a session. Learning these tools is an important aid for anyone. The happiest people on the planet have ways of relaxing themselves and decompressing from life’s inevitable, and often unsuspected, stress. One goal of EMDR therapy is to make sure that the client can take care of himself.
A note on reprocessing phases 3-6: For a single trauma reprocessing is generally accomplished within 3 sessions. If it takes longer, you should see some improvement within that amount of time. Phases One and Two lay the groundwork for the comprehensive treatment and reprocessing of the specific targeted events.
Phase 3: Assessment
The assessment phase of EMDR therapy is used to access each target in a controlled and standardized way so it can be effectively processed. Processing does not mean talking about it. See the Reprocessing sections below. The clinician identifies the aspects of the target to be processed. The first step is for the person to select a specific picture or scene from the target event (which was identified during Phase One) that best represents the memory. Then he chooses a statement that expresses a negative self-belief associated with the event. Even if he intellectually knows that the statement is false, it is important that he focus on it. These negative beliefs are actually verbalizations of the disturbing emotions that still exist. Common negative cognitions include statements such as “I am helpless,” “I am worthless,” ” I am unlovable,” “I am dirty,” “I am bad,” etc. The client then picks a positive self-statement that he would rather believe. This statement should incorporate an internal sense of control such as “I am worthwhile/ lovable/ a good person/ in control” or “I can succeed.” Sometimes, when the primary emotion is fear, such as in the aftermath of a natural disaster, the negative cognition can be, “I am in danger” and the positive cognition can be, “I am safe now.” “I am in danger” can be considered a negative cognition, because the fear is inappropriate — it is locked in the nervous system, but the danger is actually past. The positive cognition should reflect what is actually appropriate in the present. At this point, the therapist will ask the person to estimate how true he feels his positive belief is using the 1-to-7 Validity of Cognition (VOC) scale. “1” equals “completely false,” and ” 7″ equals “completely true.” It is important to give a score that reflects how the person “feels,” not ” thinks.” We may logically “know” that something is wrong, but we are most driven by how it “feels.” Also, during the Assessment Phase, the person identifies the negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) he associates with the target. The client also rates the disturbance using the 0 (no disturbance) to 10 (the highest disturbance you can imagine) Subjective Units of Disturbance (SUD) scale.
Phase 4: Desensitization
Although the eye movements (or taps, or tones) are used during the following three phases, they are only one component of a complex therapy. The use of the step-by-step eight-phase approach allows the experienced, trained EMDR clinician to maximize the treatment effects for the client in a logical and standardized fashion. It also allows both the client and the clinician to monitor the progress during every treatment session.
Phase 4: Desensitization focuses on the client’s disturbing emotions and sensations as they are measured by the SUDs rating. This phase deals with all of the person’s responses (including other memories, insights and associations that may arise) as the targeted event changes and its disturbing elements are resolved. This phase gives the opportunity to identify and resolve similar events that may have occurred and are associated with the target. That way, a client can actually surpass her initial goals and heal beyond her expectations. During desensitization, the therapist leads the person in sets of eye movement (or other forms of dual attention bilateral stimulation) with appropriate shifts and changes of focus until his SUD-scale levels are reduced to zero (or 1 or 2 if this is more appropriate). Starting with the main target, the different associations to the memory are followed. For instance, a person may start with a horrific event and soon have other associations to it. The clinician will guide the client to a complete resolution of the target. Examples of sessions and a three-session transcript of a complete treatment can be found in F. Shapiro & M.S. Forrest (2004) EMDR. New York: BasicBooks. http://www.amazon.com/EMDR-Breakthrough-Movement-Therapy-Overcoming/dp/0465043011
Phase 5: Installation
The goal of Phase 5 Installation is to concentrate on and increase the strength of the positive belief that the person has identified to replace his original negative belief. For example, the client might begin with a mental image of being beaten up by his father and a negative belief of “I am powerless.” During the Desensitization Phase he will have reprocessed the terror of that childhood event and fully realized that as an adult he now has strength and choices he didn’t have when he was young. During this fifth phase of treatment, his positive cognition, “I am now in control,” will be strengthened and installed. How deeply the person believes his positive cognition is then measured using the Validity of Cognition (VOC) scale. The goal is for the person to accept the full truth of his positive self-statement at a level of 7 (completely true). Fortunately, just as EMDR cannot make anyone shed appropriate negative feelings, it cannot make the person believe anything positive that is not appropriate either. So if the person is aware that he actually needs to learn some new skill, such as self-defense training, in order to be truly in control of the situation, the validity of his positive belief will rise only to the corresponding level, such as a 5 or 6 on the VOC scale.
Phase 6: Body scan
After the positive cognition has been strengthened and installed, the therapist will ask the person to bring the original target event to mind and see if he notices any residual tension in his body. If so, these physical sensations are then targeted for reprocessing. Evaluations of thousands of EMDR therapy sessions indicate that there is a physical response to unresolved thoughts and feelings. This finding has been supported by independent studies of memory indicating that when a person is negatively affected by trauma, information about the traumatic event is stored in motoric (or body systems) memory, rather than narrative memory, and retains the negative emotions and physical sensations of the original event. When that information is processed, however, it can then move to narrative (or verbalizable) memory and the body sensations and negative feelings associated with it disappear. Therefore, an EMDR therapy session is not considered successful until the client can bring up the original target without feeling any body tension. Positive self-beliefs are important, but they have to be believed on more than just an intellectual level.
Phase 7: Closure
Closure ends every treatment session. Sufficient closure ensures that the person leaves at the end of each session feeling better than at the beginning. If the processing of the traumatic target event is not complete in a single session, the therapist will assist the person in using a variety of self-calming techniques in order to regain a sense of equilibrium. Throughout the EMDR therapy session, the client has been in control (for instance, he is instructed that it is okay to raise his hand in the “stop” gesture at anytime) and it is important that the client continue to feel in control outside the therapist’s office. He is also briefed on what to expect between sessions (some processing may continue, some new material may arise), how to use a journal to record these experiences, and which techniques he might use on his own to help him feel more calm.
Phase 8: Reevaluation
Reevaluation opens every new session At the beginning of subsequent sessions, the therapist checks to make sure that the positive results (low SUDs, high VOC, no body tension) have been maintained, identifies any new areas that need treatment, and continues reprocessing the additional targets. The Reevaluation Phase guides the clinician through the treatment plans that are needed in order to deal with the client’s problems. As with any form of good therapy, the Reevaluation Phase is vital in order to determine the success of the treatment over time. Although clients may feel relief almost immediately with EMDR therapy, it is as important to complete the eight phases of treatment, as it is to complete an entire course of treatment with antibiotics.
Past, Present and Future
Although EMDR therapy may produce results more rapidly than previous forms of therapy, speed is not the issue and it is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust (Phase Two), while another may proceed quickly through the first six phases of treatment only to reveal, then, something even more important that needs treatment. Also, treatment is not complete until EMDR therapy has focused on the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future. Excerpts from: F. Shapiro & M.S. Forrest (2004) EMDR: The Breakthrough Therapy for Anxiety, Stress and Trauma. New York: BasicBooks. http://www.amazon.com/EMDR-Breakthrough-Movement-Therapy-Overcoming/dp/0465043011
For another description: http://www.therapyadvisor.com
One or more sessions are required for the therapist to understand the nature of the problem and to decide whether EMDR therapy is an appropriate treatment. The therapist will also discuss EMDR therapy more fully and provide an opportunity to answer questions about the psychotherapy. Once therapist and client have agreed that EMDR is appropriate for a specific problem, the actual EMDR therapy may begin.
A typical EMDR therapy session lasts from 50 to 90 minutes. The type of problem, life circumstances, and the amount of previous trauma will determine how many treatment sessions are necessary. EMDR may be used within a standard “talking” therapy, as an adjunctive therapy with a separate therapist, or as a treatment all by itself.
Approximately 24 controlled studies have investigated the effects of EMDR. These studies have consistently found that EMDR therapy effectively decreases/eliminates the symptoms of post traumatic stress for the majority of clients. Clients often report improvement in other associated symptoms such as anxiety. The current treatment guidelines of the American Psychiatric Association and the International Society for Traumatic Stress Studies designate EMDR as an effective treatment for post traumatic stress. EMDR was also found effective by the U.S. Department of Veterans Affairs and Department of Defense, the United Kingdom Department of Health, the Israeli National Council for Mental Health, the World Health Organization’s 2013 “Guidelines for the management of conditions that are specifically related to stress,” SAMHSA’s National Registry of Evidence-Based Programs and Practices, and many other international health and governmental agencies. Research has also shown that EMDR can be an efficient and rapid treatment. For more information, go to our bibliography of EMDR research.
Scientific research has established EMDR as effective for post traumatic stress. However, clinicians also have reported success using EMDR in treatment of the following conditions:
- Panic attacks
- Complicated grief
- Dissociative disorders
- Disturbing memories
- Pain disorders
- Performance anxiety
- Stress reduction
- Sexual and/or Physical abuse
- Body dysmorphic disorders
- Personality Disorders
You can find a 37 page annotated bibliography of research on the use of EMDR therapy for research on its use with PTSD and other conditions HERE.
The following international treatment guidelines recognize EMDR therapy
- American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines
– EMDR given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD.- EMDR is one of only three methods recommended for treatment of terror victims.
- Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel.
– EMDR is one of only three methods recommended for treatment of terror victims.
- California Evidence-Based Clearinghouse for Child Welfare (2010). Trauma Treatment for Children.
– EMDR and Trauma-focused CBT are considered “Well-Supported by Research Evidence.”
- Chambless, D.L. et al. (1998). Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.
– According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy.
- CREST (2003). The management of post traumatic stress disorder in adults. A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.
– Of all the psychotherapies, EMDR and CBT were stated to be the treatments of choice.
- Department of Veterans Affairs & Department of Defense (2010). VA/DoD Clinical Practice Guideline for the Management of PTSD and Acute Stress Reaction. Washington, DC.
– EMDR was one of four therapies given the highest level of evidence and recommended for treatment of PTSD.
- Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care CBO/Trimbos Intitute. Utrecht, Netherlands.
– EMDR and CBT are both treatments of choice for PTSD
- Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
– EMDR was listed as an effective and empirically supported treatment for PTSD, and was given an AHCPR “A” rating for adult PTSD. This guideline specifically rejected the findings of the previous Institute of Medicine report, which stated that more research was needed to judge EMDR effective for adult PTSD. With regard to the application of EMDR to children, an AHCPR rating of Level B was assigned. Since the time of this publication, three additional randomized studies on EMDR have been completed.
- INSERM (2004). Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France.
– Of the different psychotherapies, EMDR and CBT were stated to be the treatments of choice for trauma victims.
- National Collaborating Centre for Mental Health (2005). Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: National Institute for Clinical Excellence.
– Trauma-focused CBT and EMDR were stated to be empirically supported treatments for choice for adult PTSD.
- SAMHSA’s National Registry of Evidence-based Programs and Practices (2011). The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency of the US Department of Health and Human Services (HHS).
– This national registry (NREPP) cites EMDR as evidence-based practice for treatment of PTSD, anxiety and depression symptoms. Their review of the evidence also indicated that EMDR leads to an improvement in mental health functioning.
- Sjöblom, P.O., Andréewitch, S . Bejerot, S., Mörtberg, E. , Brinck, U., Ruck, C., & Körlin, D. (2003).Regional treatment recommendation for anxiety disorders. Stockholm: Medical Program Committee/ Stockholm City Council, Sweden.
– Of all psychotherapies CBT and EMDR are recommended as treatments of choice for PTSD.
- Therapy Advisor (2004-7).
An NIMH sponsored website listing empirically supported methods for a variety of disorders. EMDR is one of three treatments listed for PTSD. United Kingdom Department of Health (2001). Treatment choice in psychological therapies and counselling evidence based clinical practice guideline. London, England.
– Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation
- World Health Organization (2013). Guidelines for the management of conditions that are specifically related to stress. Geneva, WHO.
– Trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents and adults with PTSD. “Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (p. 1)
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